Provider Demographics
NPI:1861450512
Name:ROSELLE, GARY LEE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:ROSELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5504
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:3223 EDEN & ALBERT SABIN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-0405
Practice Address - Country:US
Practice Address - Phone:513-584-6868
Practice Address - Fax:513-584-6040
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-036345207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64761349Medicaid
OH0377131Medicaid
IN200147030Medicaid
IN200147030Medicaid
OHRO0439761Medicare PIN